The Danger Of Early Closure

I had a patient once—a fellow physician—who came to see me complaining of mid-back pain. When I examined him, I found I could reproduce his pain by pressing firmly on the spot he said was hurting him. He said pressing there also made the pain radiate around to his stomach, a phenomenon known as “referred pain” that meant his pain was almost certainly caused by a trigger point. I offered to inject it with a mixture of lidocaine and cortisone, a procedure that’s been shown in the medical literature to be helpful, but he declined, preferring instead to use over-the-counter pain relievers.

However, over the next few weeks, his pain intensified and began to interfere with his ability to work, so he arranged to have a CT of his chest and abdomen done at a nearby hospital. He then called to tell me the CT had revealed a mass in his pancreas. When the mass was removed a few weeks later, the pathology showed it to be an adencarcinoma of his pancreas. Once he’d recovered from the post-operative pain, he told me the pain in his back was gone.

I’d never before encountered visceral pain masquerading so completely and convincingly as somatic pain (that is, pain from an internal organ behaving as though it was coming from a muscle). Sometimes doctors gather all the clues correctly, think all the right things based on those clues, and still get it wrong. But in this case, another significant thought error contributed to the misdiagnosis: my tendency to come to early closure.

Early closure, it turns out, is a danger that lies in wait mostly for seasoned clinicians (far more commonly, at least, than for medical students and residents). Because seasoned clinicians rely more on pattern recognition to make diagnoses and often come to their conclusions rapidly, they’re at far greater risk for leaping toward those conclusions without examining all other relevant possibilities. Patients often present with a constellation of symptoms that don’t entirely fit the diagnosis they actually have. Often the discrepancies between these presentations and the textbook descriptions are unimportant—but sometimes those discrepancies exist not because the patient’s body hasn’t read the textbook, but because the diagnosis the doctor makes is the wrong one. Such misdiagnoses are occasionally unavoidable: the symptoms with which the patient presents are simply too far afield from the way the medical literature says the disease should present (luckily for us all, this is the exception and not the rule). At other times, however, these mistakes are made because the physician was simply in a hurry, or tired, or didn’t care enough to think through the evidence in ways he should have, saw a pattern he thought he recognized, and stopped asking the most important question a physician can ever ask: what else could this be?

It’s the same with us all. We all come to early closure all the time, forming opinions about the behavior of others without sufficient consideration of all relevant facts. We become attached to the explanations that make the most sense from the perspective of our own experience and our own point of view.

But this frequently leads to misunderstandings, sometimes with disastrous consequences. We so rarely seem to give others the benefit of the doubt, preferring instead to think the worst of them, especially when their actions produce inconveniences and difficulties for us. But the path of true humanism is paved by dialogue, not assumption—by working to bring out the potential for good in others, not for evil. Sometimes, in fact, it’s our own expectations that others will be good that brings out the good within them. The real danger of early closure in the non-medical context, then, is that we all have a tendency to fulfill the expectations of others, and if others quickly assume the worst of us, we often deliver.

I apologized to my patient for missing his diagnosis. He responded by telling me he’d agreed with my original diagnosis himself and had been floored when the CT had come back showing a pancreatic mass. We both learned from our experience that day: visceral pain can masquerade in some people as somatic pain. Fool me once, I thought, shame on you. Fool me twice, shame on me.

My patient forgave me readily, pointing out, quite correctly, that the modest delay in making the diagnosis would have no impact on the outcome whatsoever. He was right: six months after first coming to see me, he was dead. And though my mistake didn’t cause his death, it remains in my memory a stark warning of the risks of failing to maintain humility when concluding a diagnosis is “obvious.” I must remember that, though I’m usually right when I recognize a pattern, there will be times when I’m wrong. And some of those times, being wrong will mean the difference between a patient’s life and his death. Occasionally, that thought keeps me awake at night. And I often wonder: shouldn’t we worry about prejudging the motivations of others, too?

Share This Article

I’m in the process of reading How Doctors Think (Jerome Groopman) which I highly recommend to all physicians. He, like you, talks about jumping to premature diagnoses and other errors (like “diagnosis momentum”) He also, in the process, makes a great plea for understanding that we are human, and that the cognition to make a diagnosis is always affected by the emotional and social milieu.

It’s difficult sometimes to get a correct diagnosis. I had tremendous back pain that led to problems walking.

Seeing a neurologist and subsequent MRIs didn’t reveal anything out of the ordinary other than a thyroid nodule, so I saw an endocrinologist for potential hyperthyroidism as I also had massive anxiety. I was then diagnosed with General Anxiety Disorder (GAD).

Hyperthyroidism was ruled out, but my heart rate was high and it was recommended that I see a cardiologist.

The cardiologist put me on a 24-hour holter monitor thinking that nothing would be found. Turns out I have Focal Atrial Tachycardia which was causing lots of adrenaline fight/flight response and increasing back muscle tension, thus the back pain.

I’ve been on Toprol 200 mg/day for almost a year now and use Ativan occasionally for more stressful situations.

The fact that it took 3 years to figure things out was really frustrating, but the fact that it took several doctors with seemingly innocuous observations to finally make a diagnosis was infuriating. Thankfully it only took 3 years, but it cost me my job in the end. I knew I wasn’t “nuts,” but no doctor could seem to put together my symptoms. I’m glad it wasn’t a life or death situation as with your patient.

So, I can sympathize with your plight of “early closure” to some extent, but am now ultra vigilant and questioning of my doctors and will never again accept an “I don’t know” answer or an answer that I know in my gut is not right.

I know it must be tough to be a doctor, but “we” really rely on you to help when things get tough. This is the first time in my life of 50 years that I’ve ever had a major medical issue and it was terrifying and 3 years was way too long to wait for an answer.

Such significant messages couched in your personal experience and poignant example. I particularly noted these two statements:

“… by working to bring out the potential for good in others, not for evil” [emphasis mine], and

“And I often wonder: shouldn’t we worry about prejudging the motivations of others, too?”

First I think it is wise to realize we all have the capacity (potential) to do good or harm. As opposed to the view that individuals either are good or evil.

And to debate whether our predilections are one way or the other misses the point. Crucial here is that it really is only a potentiality at any given moment.

Second, I fully agree with you that our prejudices or expectations can help influence the expression of this potentiality. Indeed, every action we take does. That’s the wonder of our mutual interdependence; our co-creation of the world in which we all live, moment-to-moment.

We often think of our actions as segregable or independent. Just “doing my own thing,” or “minding my own business.” Indeed, “independence” is a deeply ingrained cultural cornerstone of the U.S. experience. But there is a danger in taking anything to an extreme, such that our belief in independence blinds us the the potential causes and effects on others of our biases, our prejudices, and our behaviors.

Once again, anyone has the potential to overcome the obstacles that are a part of this world we co-create, but with over 6 billion people on this planet, statistics assure us that not everyone will.

And so it is my hope that, one person at a time, we will seek the wisdom to examine our own biases and blind spots, and thereby “give the benefit of the doubt,” or “assume the best” of those we encounter or hear about.

In this way, perhaps we can avoid our innate proclivity to react, and for activating the fight or flight response. And may such actions thereby nourish the potential for good in others, and in ourselves.

Yes, but the analogy between a too-quick medical diagnosis and judging others is not a perfect analogy.

In one case, as in the example of your colleague with pancreatic CA, the outcome may be life-and-death for the person who is pre-diagnosed. In the other case, the person who pre-judges may poison HIM/HERSELF with prejudice, intolerance and hate.

For me, this comes down to discipline. In medical terms, this may be called watchful waiting. For your every day non-medical person, just trying to make his or her journey, it means keeping oneself in check: not being to hasty; cultivating an open mind; teaching (oneself) tolerance; meditating on fairness . . . etc. For me, at times, a lot of discipline is required. I have to tell myself firmly to stop-and-consider.

I am currently breaking away from not one but two organizations. It is hard to break away from long-term membership unless I make those organizations and the managers and key players into the bad guys. Which is not necessarily true (I don’t know the whole story behind their behaviors and motivations . . .). I am holding myself in check, and trying not to bad-mouth them; telling myself that I am reaching forward toward something that is better for me—a better fit, as they say in HR. I am not so much rejecting as reaching for something better (for me).

I wonder if diagnosticians can benefit from this analogy of mine? Could they find a “better fit,” i.e., a better diagnosis? Could they find the “best fit,” the most accurate diagnosis?

Chris: I agree; your analogy is better than mine. Diagnosticians often do engage in “watchful waiting” when their judgment tells them it’s safe. “A tincture of time” without any direct intervention often cures many ills.

1. I didn’t realize there was a label for that—and patients in my oncology practice often ask “Why didn’t my doctor look further/find it earlier?” and I tell them that I think their doctor likes them and didn’t WANT to find something ominous, so when it was pronounced to be something with an “only” before it, then that was that, and everyone was satisfied!

2. Judging people-early closure in daily life….Oh gosh, please provide the cure for this evil malady, the focus of my yearly NY resolutions! I do it all the time…driving, reading, talking, meeting people….I am glad you drew the analogy, now how to stop doing it? Mindfulness, openness, dialogue (probably not with other drivers! hee hee!) and I try to think of reasons why someone just cut me off or is driving like a nut; so until proven otherwise everyone on the road just heard bad news or is having a health emergency.

Interesting how your use of the word “closure” in your title reminds me of the death penalty. Families of the victim often use the desire for closure as the reason for having the death penalty. In this sense, there is also the danger of early closure—of executing the wrong person because the pressure for finding and punishing the perpetrator is great.

Ought to embroider this as a daily motto: What else might it be?
This will join the two “slogans” I took from my therapist (during a long and fruitful therapy):
What’s going on here?
You don’t have enough information.
“Watchful waiting” is the Rx for both the latter situations.
What’s the Rx for what else might it be? An open mind, perhaps?

“Early closure” seems to be happening more often these days in the medical field; could it have to do with the increased pressure put on doctors to see more patients in less amount of time than they used to?

Years ago, my husband went to see an orthopedic doctor about a painful bony growth on his toe. The doctor had 30 years of practice behind him, and on account of his vast experience ruled out gout and suspected a rare, fast-growing bone tumor. Because a biopsy would take most of the small toe with it, he pushed to take the whole toe, saying that if it turned out to be this kind of tumor, we would kill 2 birds with 1 stone, so to speak. Also, he was about to go on a month-long vacation….long story short, after the amputation the pathologist found that it was gout, no tumor. So yes, it’s worth taking a little more time (and perhaps getting a second opinion). Fortunately the loss of a little toe did not lead to death.

Recently a friend of ours discovered through a second opinion that what the first doctor thought was a slow-growing prostate tumor that didn’t need prompt attention was indeed a fast-moving, invasive tumor that the second doctor insisted upon removing ASAP. Why did my friend get the second opinion? Because his gut told him to.

The moral of the story? Nothing is guaranteed; we all do the best we can; we can all try to pay attention to ourselves and each other.

Good stuff here. In working clients as a coach, I find this “What else might it be?” to be a powerful question that has significant implications. As I ask them, I also have to ask it of myself. I have the all-too-human inclination that you mention to want to see the answer to help my clients get through a situation. Being in some discomfort while they and I consider the other possibilities can be almost excruciating. But the results are often worth the temporary discomfort.

Thanks for this thoughtful post, Alex. As always, I love how you weave your experience in your profession into the fabric of everyday life, using one to inform the other.

I gave up making New Year’s resolutions years ago — perhaps before I could have really benefitted from one particular one: don’t judge people prematurely. Intellectually, I know not to do it. I even use a couple of Buddhist practices to keep me from doing it. But the conditioning is so deep, that unless I’m vigilant, I jump straight to judgment.

The other night I was watching a tape of Letterman (yes, we’re fans in this household). He introduced his next guest: an actor who stars in a new version of Hawaii Five-0. This young man came out who had that Hollywood look and demeanor, complete with some kind of pompadour hairdo that must be a new style. I could feel the negative judgment forming. As the interview progressed, the negative judgment took hold (which always has that kernel in it of “I’m better than you”). And then Letterman picked up a big book and started showing photos from it. It turns out that this young actor is also a photographer and had had a book of his photos published. And impressive looking they were.

I’ve been struggling with one of the issues mentioned here: what if you judge someone in a first impression and you are wrong? We all do it, so instead of pretending we don’t, let’s figure out a mitigation.

I have come up with a happy solution. Always default to the opinion that is more favorable to the person. That is, if they say “nice hat” and you can take it two ways, then you should assume that they like your hat. And here is why:

If you assume they were making fun, but you were wrong, then you need to explain (to yourself, at least) why you projected evil intent onto this person. The badness was in your head, not theirs.

The other side of the coin is this: if you assume they were being nice, but you were wrong, then you made a mistake of assuming the best of someone. This is a comfortable and survivable mistake to make. And it is also easier to explain to yourself, and to another person (perhaps to the name-caller).

This could lead to abuse by someone pathological, and if someone continues to behave badly, then you may move your default assessment to a different place, for that person only. But for first impressions, it is behavior that is easy to self-teach, and can actually encourage and allow good behavior from people you meet. Win-win.

A couple of weeks ago, my morning paper did not arrive. I reported the problem and an hour later I saw, from my kitchen window, a woman walking onto the porch with a paper. She called through the front door “delivering your paper” and I almost just yelled “thank you” without going to the door. But then I decided to go. The woman apologized for the non-delivery and then smiled….revealing half a dozen missing teeth. Inside my head, at that moment, I began to judge her figuring she had to be some poor weirdo to have so many missing teeth. Long story short, turns out she had breast cancer–just like my sister–and had recently been told she was cancer free…which meant she could get the teeth replaced that had been destroyed by chemo. It was going to cost her a bundle but she had been saving up for it and was happy about it. We hugged, we cried and off she went. She was certainly a better woman than I.

As I nurse, I seriously struggle with early closure. There have been times when my quick judgment (maybe intuition) have saved patients’ life—is that early closure in a good way? Unfortunately there have times when my quick judgment (maybe dismissal) has missed things. It is so hard for me to take the time to dissect my quick judgment—is it early closure? Is it intuition? Is it fact based? Is it dismissal/denial?

It’s reassuring to know physicians wrestle with things like this as well.

Kayla: I’m a big believer is trusting intuition. In my view, we become guilty of early closure not when we trust our intuition, but when we do it without considering other reasonable possibilities (assuming, of course, there’s time to do that).

To Kayla, and all: there is a fascinating book named “Blink” by Malcolm Gladwell that discusses this effect that people experience. I would encourage you to take a look at it, particularly if you find yourself making life-and-death decisions in the blink of an eye, and wonder why you are so good at it. The chances are that you are really are, until and unless you slow down and try to figure out why. Then is when you may stop being as good at it.

Blink: The Power of Thinking Without Thinking is a 2005 book by Malcolm Gladwell. It presents in popular science format research from psychology and behavioral economics on the adaptive unconscious; mental processes that work rapidly and automatically from relatively little information. It considers both the strengths of the adaptive unconscious, for example in expert judgment, and its pitfalls such as stereotypes.
===[end excerpt]===

For what it is worth, I give it “two thumbs up” and have found it a source of positive energy along the lines of what I get here from HITW.

I really appreciated your article this week and all the comments that it generated. I went back to both throughout the week to re-read. An important reminder for me to maintain my humility, professionally and personally. I hope the lesson sticks!

I really love your insightful and thought-provoking posts. I also love the great discussions that ensue.

As LL pointed out above, you’ve provided a new interpretation to something I thought was related to Occam’s razor. In a general medicine clinic, musculoskeletal back pain is probably a lot more common than pancreatic cancer (or any cancer); therefore, why should the less common and less likely diagnosis be the one that rises to the top of our possible diagnoses? Isn’t this (in part) what leads to the over-testing problem we encounter in medicine today?

Doctors, like scientists, form hypotheses in the clinic based on the patient interaction, and the hypothesis must be guided by an accurate understanding of the situation. If the malady responds to the treatment, or is confirmed with an appropriate test, the hypothesis is confirmed. It seems to me that the danger comes when the patient and doctor fail to revisit the hypothesis. Sooner or later, the correct diagnosis will become apparent.

Keep up the great posts—and discussions!

J

Jim: You’re spot on. Doctors are trained to consider both the most likely diagnoses and the most dangerous (even if unlikely). But the real danger lies exactly in what you say: a failure to revisit the hypothesis when appropriate signals suggest one should.

Pain is pain is pain. At least u offered to help. i can relate to the years of frustration Amy describes above—it feels like the harder I fight to get help or be my own advocate, the less seriously my doctors take me. Beneath the anger at being dismissed…lies hopelessness. I feel like that tiny light at the end of the tunnel is dimming, and I can’t accept that the pain will never go away.

But your overall revelation is great: we shouldn’t purport to know a thing about what anyone else is going through, because we haven’t walked in their shoes.

What if giving the other person the benefit of the doubt conflicts with your intuition? If your intuition suggests the other person intends to do you bodily harm do you react according to your intuition or non-judgmentally in the absence of any other indicators?

Hmmmmm…

It begs the question, what actually is intuition? And, does intuition play a role in “judging” others?

Ecyoj: I would trust your intuition until it’s proven incorrect. Giving people the benefit of the doubt doesn’t mean turning a blind eye to the truth that many people do mean us harm

Alex,
This is a great post. It brings to mind one of my experiences in medical practice. One occurred when I was a medical resident rotating at a community hospital. One of the patients under my care for cellulitis developed subjective shortness of breath shortly before discharge. I was worried about pulmonary embolism but an ultrasound of his legs was negative for clot. Chest x-ray and VQ scanning were inconclusive. This was before the days of relying on contrast chest CT scanning. I urged pulmonary and cardiology consultants to transfer the patient to a tertiary care center for pulmonary angiogram, but they both told me that it was just bronchitis or COPD and to forget about it. He returned to the ED two days later in respiratory arrest and died. My two medical students attended his autopsy. I felt a mixture of anger and sadness. But what you said about premature closure being a tendency of seasoned clinicians is spot on. I was the inexperienced one, and yet, the fact that I had been right was no consolation. My students learned a valuable lesson, but the poor patient lost his life. That experience always reminds me to consider the worst case scenarios first. Balancing that worry with cost containment is a difficult but manageable goal most of the time.

I am having my first real encounter with the medical system as the patient. A meningioma was found, I had surgery, and the neurosurgeon, neuro-oncologist, and neurologist all said basically “won’t come back.” The last specialist, the radiation oncologist, recommends radiation “just to be safe.” This blog has helped me put these opinions in context, especially accepting my own confirmation bias—that the opinions I heard first, and liked just fine, were the correct ones; recognizing that maybe I’m not the best person to decide about my own treatment (then who?) and that maybe that last doctor just didn’t like me enough… 😉

Health Business Blog » Blog Archive » The perils of early closure in medicine and management consulting
9/20/11

[…] Happiness in this World has an interesting post from last November (which I happened to see re-posted at KevinMD), which tells the story of a misdiagnosis of one physician by another. The problem: “early closure,” or jumping to conclusions. From the blog: […]

The perils of early closure in medicine and management consulting | StigmaBot
1/10/12

[…] Happiness in this World has an engaging post from final Nov (which we happened to see re-posted during KevinMD), that tells a story of a misdiagnosis of one medicine by another. The problem: “early closure,” or jumping to conclusions. From a blog: […]